Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a CSE Competent Person.

1. IDENTIFICATION

  • Date and Time of Entry

  • Entry/Access Permit Number

  • Confined Space Location

  • Description of Works

  • Manhole No

  • Site Photo

2. PERSONNEL

  • Enter the names of Entry Personnel and Expiry Date of CSE Ticket

  • Enter the names of Surface Personnel and Expiry Date of CSE Ticket

  • Relevant Emergency contact numbers are accessible on site ?

3.ISOLATION

  • Electrical Isolation Required

  • Mechanical Isolation Required

  • Contact with System Operator Required

  • Required Isolation in Place - Checked by

  • Signiture

4. ATMOSPHERIC TESTING

  • Gas Detector Calibration Date

  • Recommended Levels

  • Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

  • Record Peak Test Readings Prior To Entry

  • Oxygen (%)

  • Explosive Gas (LEL%)

  • Hydrogen Sulphide (ppm)

  • Carbon Monoxide (ppm)

  • Other Gases Tested

  • Record any

5. VENTILATION

  • Natural

  • Forced

  • Wash Down

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE

  • Select any of the following that will be taken into consideration before entry into the Confined Space

  • Weather

  • Traffic

  • Noise

  • Catchment

  • Flow Volume

  • Trade Waste Discharge

  • Industrial/Commercial Discharge

  • Domestic Discharge

7. PERSONAL PROTECTION EQUIPMENT

  • Select relevant PPE to be worn or carried by persons entering the Confined Space.

  • First Aid Kit

  • Helmet, Boots, Safety Vest

  • Gloves

  • Eye Protection

  • Hearing Protection

  • Overalls, Chemical Suite

  • Waders

  • 2 Way Radio

  • Gas Detector

  • Self Rescue Respirator

  • Fall Arrest Device

  • Lifeline

  • Harness

  • Airline

  • Road Signage

  • Platforms

  • Barricades

  • Lighting

  • Bosun

  • Ladders

  • Man Cage

  • Fire Extinguisher

8. HOT WORK

  • Has the area been cleared of combustible materials for 15m ?

  • Have all drains within 15m been covered with a wet fireproof blanket ?

  • Will hot work be performed in the Confined Space ?

  • Are appropriate fire extinguishes on site ?<br>List the type of Extinguishers .

  • Is a water hose available & tested on site ?<br>If no, list precautions taken to substitute a water hose.

  • Is extra ventilation required ?<br>If "YES" what type and where will it be located.

  • All power leads clear of pipelines ?

  • All power leads clear of access way ?

  • Will the Hot works release toxic vapours ?<br>If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.

8.1. Welders

  • Are welding machines/gas bottles at least 8m from the manhole/pit entry ?

  • Are electric welders earthed ?

  • Are welders serviced to manufacturers specifications ?

  • Welders Name & Signature

8.2. Authority to perform "HOT WORKS" works

  • I have checked the above conditions and consider it safe to carry out this work.

  • Name & Signiture

  • Select date

9. CITY WEST WATER ENTRY

  • CONTACT CITY WEST WATER FOR ENTRY TIME - 9313 8499

  • Time phoned IN (Entry)

  • Time of intended EXIT

  • CWW Operator Name

10. APPROVAL TO ENTER

  • The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.

  • Name and Signature

  • Select date

11. JOB COMPLETION

  • All persons have left the Confined Space. No further Entries Permitted without New Permit

  • Name and Signature

  • Select date

12. CITY WEST WATER EXIT

  • CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499

  • Time of EXIT

  • CWW Operator Name

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